TX HHS Form H0065-MBIC. Hardship Form (Medicaid Buy-In for Children)
The Hardship Form (Medicaid Buy-In for Children) is designed to help individuals who have experienced financial hardship due to certain circumstances. This form can be used in situations where someone in the household has lost income due to job loss, divorce or separation, or a parent's death.
To qualify for assistance, applicants must meet specific conditions outlined on the form. These include answering "yes" to questions about income loss and providing required information. If approved, payments can be stopped for up to 3 months, with a maximum of one stop payment per 12-month period. It is essential to follow the instructions carefully and return the completed form by the due date.
Key requirements include answering four questions on the next page about everyone living in the household, signing and dating the form if applicable, and returning it via pre-paid envelope by the specified deadline. If all questions are answered "no," payment is required, and no further action is needed. For assistance or questions, call 2-1-1 or 1-877-541-7905, or visit
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